Tossing, turning, sweating, freezing, thirsty, up to the bathroom, partner snoring, child is thirsty, twitching, noises, remembering something to do tomorrow, remembering something forgotten yesterday, worry, anger, sadness… and then another day begins. Exhausted.
Insomnia strikes almost everyone at some point, especially in times of stress. For some, insomnia becomes a chronic condition. Insomnia can involve difficulty falling asleep, intermittent sleep throughout the night, early morning waking, or poor quality sleep (Society of Behavioral Sleep Medicine, 2022). The lack of sleep can cause fatigue or malaise, daytime sleepiness, concentration difficulties, and poor work performance, which can all contribute to a poor quality of life. Insomnia can feel all-consuming. Individuals with insomnia want it resolved, and fast. There is no shortage of sleep aids and products promising quality rest. It is no surprise that analysts predict the sleep aid industry is on track to hit $101.9 billion by 2023 (Segran, 2019). What if there was a better way? A more cost-effective and evidenced-based way? Well, there is! Cognitive Behavioral Therapy for Insomnia (CBT-I) provides just that. In as little as 3 sessions with a trained provider, individuals with insomnia can be well on their way to sleeping better, without all the trial and error of the latest sleep gimmick.
In celebration of Sleep Awareness Week 2022 (March 13th- 19th) and World Sleep Day (March 18th), I spoke with Dr. Ruth Gentry to learn more. Dr. Gentry completed her undergraduate work at Texas A&M and her graduate work in clinical psychology at the University of Nevada, Reno. She’ll tell you the rest:
Thank you for speaking with me about this topic. So many of my clients struggle with insomnia (as do I from time to time). The first question I would like to ask is: What led to your interest in CBT-I?
I completed my internship and postdoctoral fellowship at the West Los Angeles Veterans Affairs. My fellowship was focused on health psychology with training in pain management, behavioral weight loss treatment, and behavioral sleep medicine. I was trained by a very well respected, behavioral sleep medicine psychologist, Dr. Jennifer Martin. I saw amazing results with treatment. CBT-I was able to help veterans with severe insomnia and co-morbid medical and mental health challenges in just 3-4 sessions. My work with Dr. Martin and the veterans inspired me to continue this work in my private practice with a specialty focus on treating sleep disorders.
Tell me about your typical clients who present with insomnia.
With psychophysiological insomnia, the most common presentation are clients who are very anxious about their sleep. There is too much mental focus on sleep and what they need to do to go to sleep. Sadly, they are not even living their life because they are so focused on their insomnia. They often have a very elaborate or rigid bedtime and sleep routine, which is clearly not working. The thoughts about sleep can impact their whole day- catastrophizing about not sleeping well that night and how awful the next day will be as a result. Then they get in bed and are unable to sleep, feeding into this cycle.
How does CBT-I address insomnia and how does it differ from other treatments?
First, I would like to clarify that CBT-I is not sleep hygiene. I think most providers know what sleep hygiene is: don’t drink alcohol before bed, keep your bedroom dark, no electronics close to bed, keeping a bedtime routine, etc. The difference between sleep hygiene and CBT-I, is that CBT-I addresses the behavioral and cognitive components to insomnia. The behavioral components consist of sleep restriction and stimulus control. This involves spending less time in bed and instructing clients to get out of bed when they are not sleeping. When clients are anxious and trying to force themselves to stay in bed, a conditioning process is taking place, pairing their bed with anxiety and wakefulness. The cognitive component of CBT-I include addressing the thoughts, worries, and anxious beliefs they may have around sleep. I give my clients a measure called the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), and I will often see answers such as “I need 8 hours of sleep.” These clients are often then spending 10 hours of time in bed every night because their belief is that they must have 8 hours of sleep, which is unrealistic and contributing to more time in bed awake, probably only sleeping for 5-6 hours. The cognitive part of CBT-I then helps to identify which thoughts are unhelpful about their sleep, address catastrophizing, and teach relaxation strategies that can help to quiet their minds.
An important side note: It is important to rule out medical issues like sleep apnea because of course, CBT-I is not going to treat that. If clients are presenting with excessive daytime sleepiness, waking up with headaches, and have other comorbid health problems like high blood pressure or nocturia, the first step is a referral to a pulmonary or sleep medicine physician.
How do you address the belief that we must get 8 hours of sleep every night? I see this a lot in my practice.
One thing I like to nail down is that it isn’t the quantity of hours, but the quality of sleep that matters. In general, quality sleeping from midnight to 7am is better than getting in bed earlier and sleeping for 3 hours, then awake for 2 hours, then falling asleep for another 2 hours, etc. If you get more non-interrupted sleep, you are going to get more REM sleep. This brings me back to the fact that if you are in bed for 10 hours, but only sleeping for 5, you will develop conditioned arousal for the bed. Bed becomes the stimulus for being awake. Clients often tell me how they get so sleepy on the couch, but the moment they go to bed they are wide awake. We talk about how on the couch they are not trying to fall asleep; it is just happening. When you move yourself to bed there is sleep effort- you are trying to fall asleep, and your body knows bed as the place you don’t sleep. This really gets at stimulus control. I don’t want my clients in bed trying to fall asleep; that is just strengthening this conditioning. I want them to get out of bed when they can’t sleep. Try some relaxation strategies or read a book with a lamp (no screens!) in another space until they are sleepy again.
I have several clients in my caseload who tend to stay up until 3am or 4am and then sleep until noon. Is there any problem with that?
I’m glad you brought that up! There is a difference between psychophysiological insomnia and a circadian rhythm sleep disorder (CRSD). Of the CRSDs, I most often see delayed sleep phase type. I have seen so many individuals diagnosed with insomnia who do not have insomnia, but instead have this disorder. These individuals can sleep, it is just not during “normal” hours. I have had clients in my office in tears when they learn this is their diagnosis- tears of relief because they have been called “lazy” or all other sorts of inaccurate and judgmental labels. The treatment is different for this disorder and includes moving their rise time in the morning with light therapy and utilizing melatonin at a specific time in the evening. Clients really need to be motivated for this treatment because it can be challenging. If there are any co-morbidities like depression, making it even harder to get out of bed, it can be especially challenging.
Are there any groups you see presenting with insomnia most often?
There are higher rates of insomnia in women, which may be because we also see higher rates of depression and anxiety in women. Hormonal and environmental factors may play a role. More specifically, there are higher rates in older women. Older adults, and especially postmenopausal women, have higher rates of sleep apnea. You combine that with retirement and lack of a schedule, and sleep disorders can arise. It is sad; I see many older adults in my clinic who assume because they are older that they are supposed to sleep poorly. One of the first things I do is educate them about the fact that they can still have sleep quality even if they are not sleeping for 8 hours every night.
The other major group experiencing insomnia is veterans. Huge. It is important to note that insomnia is a significant risk factor for suicide, especially in veterans. This is so important, and I make sure to educate medical residents and my own trainees about this: Do not just look past someone’s sleep. People think if you treat anxiety, depression, PTSD, etc., that insomnia just gets better. That is not true. There is research demonstrating that we can treat depression, anxiety, and even PTSD, with psychotherapy and medication, but insomnia is often still there posttreatment (Carney et al., 2017; Schoenfeld et al., 2012). The other symptoms get better, but the patient will still be reporting insomnia. This is why it is so important that we do specific treatment for insomnia. We can’t just assume it is going to get better if you treat the other disorders. In my practice I see many patients who have a primary therapist, and I see them as an adjunct for a few sessions to do CBT-I.
Covid has also increased rates of insomnia in everyone, and specifically rates in teenagers is rising.
How many sessions are in a typical CBT-I treatment?
It depends. Some VAs are implementing it in primary care settings in about 3 sessions. Three to 6 sessions is pretty typical, but with more complicated presentations and comorbidities, it may take longer. One thing that excited me about CBT-I is that it can be a gateway to engaging in more intensive therapy, especially for PTSD. For example, at the VA, a lot of veterans were hesitant to go to treatment for their PTSD, but they would go to treatment for their insomnia. The changes with their sleep encouraged them to seek further treatment for PTSD.
Tell me your thoughts about medications for sleep.
Sadly, with Covid, I think we’ve seen the increased use of pharmaceuticals all around. The ones that I would avoid are zolpidem (Ambien) and benzodiazepines because they can impact REM sleep, make sleep apnea worse, and there is more research coming out that long-term use could contribute to cognitive decline and dementia. A more popular medication right now for sleep is trazodone, which is an antidepressant. I think there is a time and place for medication use. Covid has been a time when short-term use has been effective. Divorce or loss of loved ones is another time short-term use can be helpful. The goal being short-term use, and tapering at the right time. Another concern with medications is the combination of medications. If you combine opiate medications with benzodiazepines, or even zolpidem, the combination can suppress the respiratory system. This is life-threatening. And of course, can be compounded by alcohol use.
The American Academy of Sleep Medicine recommends CBT-I as the front-line treatment for insomnia, not medication!
Could you share some resources to learn more about CBT-I and how one might find a provider?
There are two great CBT-I self-help books written by Rachel Manber, Ph.D. and Coleen Carney, Ph.D.: 1) Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain, and 2) Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep.
I often have clients read these books while participating in therapy. The books address the sleep restriction piece, but this can be difficult for clients to do on their own. The books really help normalize what my clients are experiencing- that they are not the only ones with worrisome thoughts about insomnia.
To find a provider, the Perelman School of Medicine has a CBT-I Provider Directory
What a wealth of information about an incredible treatment. Thank you!
Carney, C.E., Edinger, J.D., Kuchibhatla, M., Lachowski, A.M., Bogouslavsky, O., Krystal, A.D., & Shapiro, C.M. (2017). Cognitive behavioral insomnia therapy for those with insomnia and depression: A randomized controlled clinical trial. Sleep, 40(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806549/
Carney, C.E. & Manber, R. (2009). Quiet your mind and get to sleep: Solutions to insomnia for those with depression, anxiety, or chronic pain. New Harbinger.
Carney, C.E. & Manber, R. (2013). Goodnight mind: Turn off your Noisy thoughts and get a good night's sleep. New Harbinger.
Morin, C.M. Valliéres, A., & Ivers, H. (2007). Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). Sleep, 30(11), 1547–1554. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082102/
Schoenfeld, F.B., DeViva, J.C., & Manber, R. (2012). Treatment of sleep disturbances in posttraumatic stress disorder: A review. Journal of Rehabilitation Research and Development, 49(5), 729-752. https://www.rehab.research.va.gov/jour/2012/495/pdf/schoenfeld495.pdf
Segran, E. (2019). The $70 billion quest for a good night’s sleep. Fast Company. https://www.fastcompany.com/90340280/the-70-billion-quest-for-a-good-nights-sleep
Society of Behavioral Sleep Medicine (2022). Adult insomnia. https://www.behavioralsleep.org/index.php/sbsm/about-adult-sleep-disorders/adult-insomnia